BlueCross BlueShield of Tennessee Medical Policy Manual

End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema


End-diastolic pneumatic compression has been investigated in the treatment of peripheral vascular disease, venous stasis, and lymphedema. Timed, sequential inflation during the end-diastolic portion of the cardiac cycle is applied to a boot enclosing the foot or ankle, or extending from the toes to the groin, and is designed both to allow maximal arterial flow into the leg and to expel venous blood and lymphatic fluid (e.g. The Circulator Bootâ„¢, Multicrus Circulator Bootâ„¢). Therapy is typically offered in a series of 40-minute sessions in an office setting.

The end-diastolic pneumatic compression boot includes the following components: a heart monitor to detect the QRS complex of the electrocardiogram (EKG) and to appropriately time boot compressions in the end portion of the heart cycle; a rapid action valve assembly capable of both pressurizing and exhausting the boots; rigid, adjustable long boots to enclose the leg from groin to toes; and double-walled plastic bags to enclose the treated portion of the leg and to contain the compressed air.

The end-diastolic compression device is distinctly different from single and multi-chambered lymphedema devices (used in the presence of significant lymphedema) and intermittent compression pumps (used for DVT prevention). The latter 2 devices do not require synchronization with the cardiac cycle whereas the end diastolic pump relies on EKG input to apply timed compression just prior to the next QRS complex thereby reducing afterload and cardiac work. This same synchronized compression technology is used under direct supervision by a physician to increase in cardiac output; and in that setting is known as enhanced external counterpulsation.

NOTE: Lymphedema devices, intermittent compression pumps and enhanced external counterpulsation intended to treat decreased cardiac output are NOT addressed by this policy.




Well-designed studies, which evaluate the clinical importance of end-diastolic pneumatic compression devices for the treatment of vascular disease and related conditions, continue to be lacking. The available evidence is small case series which are outdated, and no randomized controlled trials are available regarding this technology. Therefore, the technology is considered investigational.


Alvarez, O., Wendelken, M., Markowitz, L. and Comfort, C. (2015, November) Effect of high-pressure, intermittent pneumatic compression for the treatment of peripheral arterial disease and critical limb ischemia in patients without a surgical option. Wounds, 27 (11),293-301. Abstract retrieved July 25, 2017 from PubMed database.

Berliner, E., Ozbilgin, B., and Zarin, D., (2003) A systematic review of pneumatic compression for treatment of chronic venous insufficiency and venous ulcers. Journal of Vascular Surgery, 37, 539-44. (Level 2 evidence)

Buschmann, E., Brix, M., Li, L., Doreen, J., Zietzer, A., Li, M., et. al. (2016) Adaptation of external counterpulsation based on individual shear rate therapy improves endothelial function and claudication distance in peripheral artery disease. Vasa (European Journal of Vascular Medicine), 45 (4), 317-24. Abstract retrieved July 25, 2017 from PubMed database.

Moran, P., Teljeur, C., Harrington, P., and Ryan, M. (2015, February) A systematic review of intermittent pneumatic compression for critical limb ischaemia. Vascular Medicine, 20 (1), 41-50. Abstract retrieved July 24, 2018 from PubMed database.

U. S. Food and Drug Administration (2009, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K020857. Retrieved December 5, 2012 from

U. S. Food and Drug Administration (2009, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K082134. Retrieved April 18, 2011 from

Winifred S. Hayes Medical Technology Directory (2013, July, last update search June 2017) Intermittent pneumatic compression for peripheral arterial disease. Retrieved July 25, 2017 from (47 articles and/or guidelines reviewed)




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